FORM – A
(See clause (d) of rule 2 and sub rule (1) of rule 3)
Serial No…………
APPLICATION FOR OPENING OF AN ACCOUNT UNDER SENIOR CITIZEN’S SAVING SCHEME 2004

To
The Postmaster /In charge
__________________________ (Name of the Deposit Office)
__________________________
__________________________
Name of Agent (in case of the account introduced through agent ) ………………………………………………………………………….
Agency Code No……………….. dated …………………… valid upto …………………………………………
Sir,
1. I. …………………………………Son / daughter / wife of ………………………………………………………… PAN No. (of
applicant) …………………………………. a permanent resident of …………………………………………………………….aged ……….. years, hereby apply for opening of an account under the Senior Citizens Savings Scheme, 2004, (hereinafter referred to as the said scheme), in my name/jointly in my name and my spouse______________________(name and address of spouse with age)* and tender herewith Rs_________(Rupees_____________________________) in cash/cheque/demand draft, the particulars of which are filled in the enclosed ‘ pay-in-slip (Form-D), towards deposit in the account.
2. I/We* hereby declare that,-
i. I/We* have clearly understand the Senior Citizens Savings Scheme Rules, 2004 governing the accounting under the said scheme, as amended from time to time (hereinafter referred to as the said rules);
ii. I/We* shall abide by the said rules in letter and spirit ;
iii. The details of other account opened earlier by me/us* under the said scheme, are as under :
Sl No Name of the depositor(s) &
type
of account (individual /joint)
Name and address of the
Deposit office
Account Number
with
date of opening
Amount of deposit
1
2
3
iv. I/We* shall adhere to the ceiling on deposits, holding the deposits in all the accounts opened by me/us* together, as specified in rule 4 and amended from time to time. In case, at any time, any excess deposit is found, such excess deposit will be refunded to me/us* after recovery of excess interest under sub-rule (8) of rule 7.
3. I nominate the following person/persons, mentioned below, to whom, to the exclusion of all other persons, in the event of my death the amount standing to my credit in the account would be payable in accordance with the provisions contained in rule 6:
Sl
No
Name(s)of the nominee(s)
along with relationship with the
depositor
Permanent address Date(s) of birth of
nominee(s) in case of a
minor/age in other case(s).
Share of the
nominee(s) in the
amount payable.
1
4. (a) As the nominee(s) at Serial No.(s)_________________ above is/are minor(s), I appoint Shri/Smt/Kumari ____________________
[Name(s) with permanent address(es) of the person(s) in respect of each minor nominee] to receive the sum due under the said account in
the event of my death during the minority of the nominee(s).
Signature/Thumb Impression of the depositor
Witness (Signature ,name & address)
1. _________________________________
2. _________________________________ Date_______________ at (Place)________________
Paste here a copy of
recent photograph
(Joint photograph of
both the Depositor &
Spouse in case of a
joint account)
My/our* specimen signature (Thumb impression), are as below :
i. First depositor :
1. 2 3.
ii. #Joint depositor :
1. 2 3.
# Witness _________________ # Witness ____________________ # Witness ________________________
(Countersigned Postmaster/incharge) (Countersigned Postmaster/incharge) (Countersigned Postmaster/incharge)
Date________& office seal) Date________& office seal) Date________& office seal)
5 I also declare that the information provided by me/us* in the application herein above, is true to the best of my/our knowledge and belief and in case, at any time, any of the information and/or declaration, is found false, no interest on the deposits shall be payable to me/us*, the deposit office shall close the account(s) and refund the deposits after recovery of the interest, if any, already paid on the deposits.
Yours faithfully,
(Signature of the applicant)
(Present Postal Address)
Date_______________
Place ______________
Enclosures
1 Age proof
2 Copy of receipted application form for allotment of PAN, if PAN is not allotted.
3 Pay-in-slip (form D), duly filled in along with amount of deposit.
4 Certificate from the employer as specified in sub-clause (ii) of clause (d) of rule 2._____________________________________________________________________________________________________________
* Strike out which ever is not applicable
** 1. The applicant(s) who are not assessed to income tax, may furnish a self declaration, that their income from all sources (including the interest, income from the account to be opened vide this application) does not cross the exemption limit and the applicant is not required to obtain PAN under Income Tax Act, 1961, as amended from time to time.
2. All other applicants shall mention the PAN No. compulsorily and in case they have not so far been allotted PAN by the Income Tax Authorities, attested photocopy of the receipted application form for allotment of PAN should be attached to the application form.
# In case of thumb impression :
Note : 1 Self attested copies of any of the following documents can be enclosed as age proof : Birth certificate issued by the Municipal authority/ Gram panchayat/District Office of the Registrar of Births and Deaths; Voter Identity card issued by the Election Commission of India ; PAN card ; passport; Ration card ; Date of birth certificate from the school last attended by the applicant or any other recognized educational institution or driving license issued by the local licensing authority.
2 Originals of the document attached, should also be produced simultaneously for verification and return immediately.
____________________________________________________________________________________
FOR THE USE OF DEPOSIT OFFICE
The account has been opened on _____________________ with Rs __________ (Rupees____________________________) under the
Senior Citizens Savings Scheme, 2004. Account No._______________ Ledger folio No._________________
Agents name, agency code number, date & validity have been entered in the ledger folio as well as Pass book (in case of account introduced
through agent).
Pass Book No______________ has been issued.
Date___________________. Signature of the incharge of Deposit Office
(alongwith name & designation stamp)